Randomized clinical trial comparing endovenous
laser ablation, radiofrequency ablation, foam
sclerotherapy, and surgical stripping for great
saphenous varicose veins with 3-year follow-up
Lars Rasmussen, DMSC, Martin Lawaetz, MS, Julie Serup, MS, Lars Bjoern, MD, Bo Vennits, MD,
Allan Blemings, MSc, and Bo Eklof, MD, Naestved, Denmark
Introduction: This study compares the outcome 3 years after
treatment of varicose veins by endovenous laser ablation
(EVLA), radiofrequency ablation, ultrasound-guided foam
sclerotherapy (UGFS), or surgery by assessing recurrence,
Venous Clinical Severity Score (VCSS), and quality of life
(QOL).
Methods: A total of 500 patients (580 legs) were randomized to
one of the three endovenous treatments or high ligation and
stripping of the great saphenous vein (GSV). Follow-up
included clinical and duplex ultrasound examinations and
VCSS and QOL questionnaires. Kaplan-Meier (KM) life-table
analysis was used. P values below .05 were considered statis-
tically signicant.
Results: At 3 years, eight (KM estimate, 7%), eight (KM
estimate, 6.8%), 31 (KM estimate, 26.4%), and eight (KM
estimate, 6.5%) of GSVs recanalized or had a failed stripping
procedure (more than 10 cm open reuxing part of the
Varicose veins are common and affect approximately
25% of Western adults.1 The condition is most often associ-
ated with great saphenous vein (GSV) reux. Until recently,
the gold standard treatment of such condition has been high
ligation combined with stripping and phlebectomies. Such
treatment efciently improves symptoms and quality of life
(QOL).2,3 However, the rate of recurrence, which may be
caused by neovascularization, progression of disease, or
technical or tactical errors, is high.4-7
In the recent decade, minimally invasive treatments,
based on radiofrequency ablation (RFA) or endovenous
laser ablation (EVLA) of the saphenous veins (thermoabla-
tion) has more or less replaced surgical stripping in
the U.S., whereas in Europe, stripping is still the most
used treatment. In addition, ultrasound-guided foam
sclerotherapy (UGFS) has become increasingly popular.
From the Danish Vein Centers and Surgical Center Roskilde.
Author conict of interest: none.
Reprint requests: Dr Lars Rasmussen, The Danish Vein Centers, Eskadrons-
vej 4A, 4700 Naestved, Denmark (e-mail: lhr@varix.dk).
The editors and reviewers of this article have no relevant nancial relation-
ships to disclose per the Journal policy that requires reviewers to decline
review of any manuscript for which they may have a conict of interest.
2213-333X/$36.00
Copyright 2013 by the Society for Vascular Surgery.
http://dx.doi.org/10.1016/j.jvsv.2013.04.008
treated GSV; CLF, EVLA, UGFS, and stripping, respec-
tively; P < .01). Seventeen (KM estimate, 14.9%), 24 (KM
estimate, 20%), 20 (KM estimate, 19.1%), and 22 (KM
estimate, 20.2%) legs developed recurrent varicose veins
(P [ NS). The patterns of reux and location of recurrent
varicose veins were not different between the groups. Within
3 years after treatment, 12 (KM estimate, 11.1%), 14
(KM estimate, 12.5%), 37 (KM estimate, 31.6%), and 18
(KM estimate, 15.5%) legs were retreated in the CLF,
EVLA, UGFS, and stripping groups, respectively (P < .01).
VCSS, SF-36, and Aberdeen QOL scores improved signi-
cantly in all the groups with no difference between the
groups.
Conclusions: All treatment modalities were efcacious and
resulted in a similar improvement in VCSS and QOL. How-
ever, more recanalization and reoperations were seen after
UGFS. (J Vasc Surg: Venous and Lym Dis 2013;1:349-56.)
Indeed, in the American guidelines for treatment of venous
disease, thermoablation is preferred instead of surgical
stripping.8 According to the guidelines, such preference is
based on the patients recovery, which, in some studies,
appears to be easier following endovenous treatment. In
addition, several studies have described a high degree of
efcacy regarding endovenous ablation of the GSV in the
short and medium term.9 However, little is known
regarding the difference in clinical recurrence between
the endovenous methods and surgery.10 The present
randomized trial, which compares RFA, EVLA, UGFS,
and stripping, was initiated in 2007. The short-term results
(1-year) were published in 2011.11 The present publication
report the medium-term (3-year) outcome and describes
the clinical and ultrasound recurrence, number of reopera-
tions, Venous Clinical Severity Score (VCSS), and QOL.
The regional ethics committee approved the study. All
patients gave informed consent.
METHODS
The study was conducted in two private surgical
centers, which work under contract to the national
health care insurance in Denmark. The primary endpoint
was closed or absent GSV. An open reuxing segment of
the treated part of the GSV of 10 cm or more was
349
 JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
350 Rasmussen et al October 2013

RFA A

RFA

Fig 1. CONSORT ow chart. EVLA, Endovenous laser ablation; RFA, radiofrequency ablation; UGFS, ultrasound-
guided foam sclerotherapy.

considered a failure to strip the vein (technical failure) or a solution of 0.1% lidocaine with adrenaline and bicar-
recanalization. Secondary endpoints were the presence of bonate. A light sedation with midazolam and alfentanil or
varicose veins during follow-up, frequency of reoperations, diazepam was administered intravenously in most cases.
VCSS, and QOL. The details of the methodology have The surgical procedure was carried out through a 4- to
been previously described.11 In brief, consecutive patients 6-cm incision in the groin, with ush division and ligation
with symptomatic varicose veins and GSV incompetence, of the GSV and division and ligation of all tributaries. The
CEAP C2-4EpAsPr, were randomized to the trial using GSV was then removed to just below the knee using a pin
sealed envelopes. Exclusion criteria were duplication of stripper.
the saphenous trunk or an incompetent accessory GSV The CLF procedure was performed according to the
(AAGSV), small saphenous or deep venous incompetence, manufacturers recommendations.12 The GSV was cannulated
previous deep vein thrombosis, arterial insufciency, or
a tortuous GSV rendering the vein unsuitable for endove-
nous treatment. All treatments and assessments were per- Table I. Baseline characteristics in patients treated for
formed by one of three vascular and general surgeons varicose veins and GSV incompetence
with experience in the management of venous disease.
Bilateral treatment was permitted, provided both limbs RFA EVLA UGFS Stripping
received the same treatment during the same operation. No. of patients 125 125 125 124
Patients who had undergone previous high ligation or No. of legs 148 144 144 142
phlebectomies were included in the trial. The patients Bilaterala 23 19 19 18
were treated with one of the following methods: RFA Age, yearsb 51 (23-77) 52 (18-74) 51 (18-75) 50 (19-72)
c
Female 70 72 76 77
(ClosureFast [CLF]; Covidien, Manseld, Mass), EVLA
CEAP C2-C3a 92 95 96 97
(ELVES, Ceralas D 980 or D 1470, bare ber; Biolitec, CEAP C4-C6a 8 5 4 3
Bonn, Germany), UGFS with Aethoxysclerol 3%, 2-mL
solution mixed with 8-mL air according to the method EVLA, Endovenous laser ablation; GSV, great saphenous vein; RFA, radio-
frequency ablation; UGFS, ultrasound-guided foam sclerotherapy.
of Tessari (Polidocanol; Kreussler, Wiesbaden, Germany), a
% of legs.
or PIN stripping. All treatments were performed in a treat- b
Mean (range).
ment room under tumescent local anesthesia using c
% of patients.
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
Volume 1, Number 4 Rasmussen et al 351

Fig 2. Kaplan-Meier (KM) plot of open reuxing great saphenous veins (GSVs). The KM gures represent time to the
event. CIs, Condence intervals; EVLA, endovenous laser ablation; RFA, radiofrequency ablation; UGFS, ultrasound-
guided foam sclerotherapy.

just below the knee, or at the lowest point of reux on the
thigh. The ber or catheter was advanced to 1 to 2 cm below
the saphenofemoral junction and withdrawn during ablation.
The EVLA procedure was performed under duplex guidance
with a 980-nm diode laser for the rst 17 legs, and a 1470-
nm for the rest using 12-watt power. Foam was injected
through one or two intravenous cannulas in the GSV at knee
level and in the thigh. Before injection of the foam, the patient
was placed in Trendelenburg position. The progression of
foam in the GSV was followed with ultrasound to ensure
a complete lling to the junction and subsequent spasm of
the vein. When this was achieved, further injection was
stopped. Varicose veins were removed by miniphlebectomies
during the same procedure in all the treatment groups.
Assessments. The patients were examined at the time
of randomization, and after 3 days, 1 month, and 1 and 3
years. The present report describes the ndings at 1 to 3
years. It is intended to continue the follow-up again at
5 years after the treatment. At the initial visit, the surgeon
obtained the medical history, performed a clinical and
duplex examination, and determined the CEAP class and
VCSS.13,14 The duration of reux and the diameter of the

Fig 3. Kaplan-Meier (KM) plot of recurrent varicose veins. The KM gures represent time to the event. CIs,
Condence intervals; EVLA, endovenous laser ablation; RFA, radiofrequency ablation; UGFS, ultrasound-guided foam
sclerotherapy.
 JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
352 Rasmussen et al October 2013

Table II. Topographical sites of REVAS: Number of recurrences and pattern of reux

RFA EVLA UGFS Stripping P

Total legs 148 144 145 143

Clinical recurrence 17 (11) 24 (17) 20 (14) 22 (15) .66
Reux in the groin 0 (0) 1 (4) 4 (20) 0 (0) .034
Reux in thigh 10 (59) 17 (71) 9 (45) 14 (64) .28
Reux in popliteal fossa 0 (0) 1 (4) 1 (5) 0 (0) .57
Reux in lower leg, ankle, and foot 12 (71) 18 (75) 5 (25) 13 (59) .047
Other 0 (0) 0 (0) 1 (5) 0 (0) .39

EVLA, Endovenous laser ablation; REVAS, REcurrence after VAricose vein Surgery; RFA, radiofrequency ablation; UGFS, ultrasound-guided foam
sclerotherapy.
Numbers shown as number of legs (% of recurrences).

GSV 3 cm below the saphenofemoral junction were
measured. The Aberdeen Varicose Vein Symptom Severity
Score (AVVSS) and the Medical Outcomes Study Short
Form 36 (SF-36; Quality Metric, Lincoln, RI) health-
related QOL score were completed by the patients and
recorded by the research nurse. The AVVSS is a validated
instrument for measurement of disease-specic QOL in
patients with varicose veins. It produces a score from 0 (no
venous symptoms) to 100 (worst venous symptoms).15
The SF-36 is a generic QOL instrument, which consists
of eight domains: physical functioning, role e physical,
bodily pain, general health, vitality, social functioning,
role e emotional, and mental health. Each domain is
scored from 0 (worst) to 100 (best).16
Statistical analysis. All analyses were assessed for the
full analysis set, comprising all patients undergoing treat-
ment. The primary endpoint, closed or absent GSV, and
secondary endpoints, recurrent varicose veins and freq-
uency of reoperations, were analyzed by Kaplan-Meier
(KM) survival methods as time to rst endpoints. The
P value represents a comparison across all treatment groups
(ie, testing the hypothesis that there are equal treatment
effects across all groups). QOL endpoints, AVVSS, SF-36,
and VCSS were analyzed using analysis of covariance. The
analysis was performed in SAS version 9.1 (SAS Institute,
Cary, NC).
RESULTS
A total of 500 consecutive patients (580 legs) were
randomized to receive treatment. The number of patients
and legs treated and examined at follow-up is shown in the
CONSORT diagram (Fig 1). Baseline patient characteristics
are shown in Table I. The groups were comparable with
regard to patient characteristics and CEAP classication of
the treated legs. Nine, nine, 10, and 16 patients had under-
gone previous high ligation and/or phlebectomies in the
CLF, EVLA, foam, and stripping group, respectively.
Detailed information regarding treatment characteristics
has been published before.11
GSV data. The KM plot of the open, reuxing
GSVs are shown in Fig 2. The KM gures represent
time to the event, and the probability on the plots is

Fig 4. Kaplan-Meier (KM) plot of reoperations. The KM gures represent time to the event. CIs, Condence intervals;
EVLA, endovenous laser ablation; RFA, radiofrequency ablation; UGFS, ultrasound-guided foam sclerotherapy.
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
Volume 1, Number 4 Rasmussen et al 353

Fig 5. Venous Clinical Severity Score (VCSS). CIs, Condence intervals; EVLA, endovenous laser ablation; RFA,
radiofrequency ablation; UGFS, ultrasound-guided foam sclerotherapy.

freedom from the event. The KM estimates are 1-KM
and represent the percentage of patients who had
failure, recurrent varicose veins, or reoperation. Eight
(KM estimate, 7%), eight (KM estimate, 6.8%), 31 (KM
estimate, 26.4%), and eight (KM estimate, 6.5%) of
GSVs were recorded as having open and reuxing
segments of 10 cm or more during the rst 3 years in
the CLF, EVLA, UGFS, and stripping group, respec-
tively (P < .0001).
Clinical recurrence and pattern of reux. The KM
plot of legs with recurrent varicose veins is shown in
Fig 3. Recurrent varicose veins were recorded in 17
(KM estimate, 14.9%), 24 (KM estimate, 20%), 20 (KM
estimate, 19.1%), and 22 (KM estimate 20.2%) legs during
the 3 years in the CLF, EVLA, UGFS, and stripping group,
respectively (P .6596). Table II shows the distribution of
the recurrent varicose veins. More patients in the UGFS
group had reux in the groin compared with the other
groups (P .034).
Reoperations. The KM plot of legs with reoperations
is shown in Fig 4. Twelve (KM estimate, 11.1%), 14 (KM
estimate, 12.5%), 37 (KM estimate, 31.6%), and 18 (KM
estimate, 15.5%) legs were retreated in the CLF, EVLA,
UGFS, and stripping group, respectively, during the 3-year

Fig 6. Aberdeen Varicose Vein Severity Score (AVVSS). CIs, Condence intervals; EVLA, endovenous laser ablation;
RFA, radiofrequency ablation; UGFS, ultrasound-guided foam sclerotherapy.
 JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
354 Rasmussen et al October 2013

Table III. SF-36 health-related QOL outcomes after treatment of varicose veins

SF-36 Pretreatment 1-year 2-year 3-year Pa to 3 years

PF
RFA 84.05 (18.50) 92.22 (12.62) 89.57 (19.83) 88.03 (17.12) .0101
EVLA 83.16 (16.85) 92.02 (11.61) 88.32 (18.77) 91.46 (13.82) <.0001
UGFS 83.49 (17.72) 91.33 (14.93) 90.5 (15.7) 88.98 (18.21) .0224
Stripping 83.31 (18.89) 92.82 (13.35) 92.69 (12.06) 90.56 (15.23) .0008
RP
RFA 87.15 (21.44) 94.65 (10.64) 92.84 (16.79) 88.08 (21.47) .7115
EVLA 83.80 (22.31) 93.51 (14.78) 90.21 (19.64) 90.08 (19.37) .0054
UGFS 86.49 (21.48) 90.36 (20.56) 91.01 (17.73) 89.7 (20.10) .0898
Stripping 85.35 (20.38) 93.41 (16.32) 93.75 (16.67) 90.84 (19.80) .3390
BP
RFA 72.71 (22.37) 89.92 (16.85) 87.78 (19.36) 85.35 (19.93) <.0001
EVLA 70.94 (20.96) 88.43 (19.55) 83.34 (21.21) 81.22 (26.00) .0013
UGFS 71.40 (20.37) 85.11 (23.45) 83.83 (21.50) 85.74 (20.61) <.0001
Stripping 71.30 (22.05) 88.77 (17.11) 89.65 (17.73) 87.86 (19.49) .0001
GH
RFA 62.38 (13.30) 67.08 (11.82) 65.33 (12.38) 62.53 (15.31) .6055
EVLA 60.55 (13.76) 64.90 (11.99) 63.38 (14.14) 61.11 (15.24) .5638
UGFS 62.58 (15.00) 63.36 (18.31) 62.79 (15.98) 65.55 (14.77) .2054
Stripping 63.57 (15.01) 66.02 (14.00) 66.58 (12.53) 65.14 (15.71) .4618
VT
RFA 66.99 (19.30) 76.00 (17.51) 79.34 (15.86) 75.56 (19.26) <.0008
EVLA 64.68 (18.60) 77.74 (14.03) 72.59 (16.65) 74.60 (17.74) <.0001
UGFS 68.07 (20.47) 73.20 (22.67) 73.46 (17.76) 74.17 (20.77) .0910
Stripping 66.90 (21.53) 76.99 (15.54) 77.22 (14.88) 75.32 (18.38) .0070
SF
RFA 93.15 (14.38) 97.11 (84.45) 97.56 (11.19) 93.95 (16.21) .8255
EVLA 92.93 (15.74) 96.51 (11.22) 94.13 (18.03) 92.86 (16.30) .8525
UGFS 92.07 (18.41) 93.10 (16.51) 95.47 (12.49) 95.75 (12.72) .3647
Stripping 90.36 (17.56) 95.19 (11.60) 96.52 (10.39) 96.77 (8.93) .0068
RE
RFA 91.67 (16.02) 94.50 (11.02) 95.58 (12.53) 92.95 (17.63) .8807
EVLA 88.67 (20.40) 95.95 (10.15) 91.77 (18.93) 89.42 (21.85) .5551
UGFS 92.41 (16.73) 91.92 (17.11) 92.02 (14.36) 91.20 (18.42) .5562
Stripping 88.17 (18.68) 94.20 (14.02) 95.52 (12.71) 94.83 (14.29) .0243
MH
RFA 80.18 (14.70) 87.08 (11.94) 86.89 (13.58) 86.62 (13.89) .0039
EVLA 80.34 (15.05) 87.70 (10.51) 85.90 (13.48) 83.97 (15.87) .0914
UGFS 83.00 (16.05) 84.58 (15.77) 83.91 (14.03) 84.34 (16.38) .8055
Stripping 79.27 (16.04) 85.92 (12.18) 87.28 (11.37) 84.83 (13.21) .1305
MCS
RFA 53.97 (8.51) 56.52 (6.17) 57.26 (6.82) 56.34 (7.30) <.0001
EVLA 53.72 (8.99) 56.74 (5.44) 55.92 (6.84) 53.90 (10.13) <.0001
UGFS 55.14 (8.87) 54.91 (8.21) 54.82 (6.74) 55.32 (9.19) <.0001
Stripping 53.03 (9.03) 55.69 (6.39) 56.50 (5.47) 55.89 (6.27) <.0001
PCS
RFA 49.11 (8.43) 53.24 (5.32) 52.09 (7.27) 50.66 (7.77) <.0001
EVLA 48.27 (7.41) 52.62 (5.98) 51.12 (7.66) 52.33 (6.32) <.0001
UGFS 48.25 (8.03) 52.14 (7.38) 51.76 (7.93) 51.89 (8.08) <.0001
Stripping 49.20 (7.89) 53.51 (5.91) 53.11 (5.65) 52.27 (7.34) <.0001

BP, Bodily pain; EVLA, endovenous laser ablation; GH, general health; MCS, mental component summary; MH, mental health; PCS, physical component
summary; PF, physical functioning; QOL, quality of life; RFA, radiofrequency ablation; RE, roleeemotional; RP, roleephysical; SF, social functioning; UGFS,
ultrasound-guided foam sclerotherapy; VT, vitality.
Values are in mean (standard deviation).
a
P values are adjusted for baseline levels of the respective SF-36 scores.

follow-up (P < .0001). Most patients were treated with
UGFS, in some cases combined with phlebectomies, which
is standard practice in our clinics.
VCSS. The VCSS score improved signicantly in all
groups (P < .0001), with no signicant difference between
the groups at any point in time (Fig 5). The improve-
ment lasted throughout the 3 years. The mean (standard
deviation) VCSS at the start of the study was 2.95 (2.06),
2.68 (2.25), 2.66 (1.45), and 2.75 (1.62) and was reduced
to 0.44 (1.82), 0.34 (1.3), 0.15 (0.4), and 0.3 (0.5) at 3
years in the CLF, EVLA, UGFS, and stripping group,
respectively.
AVVSS. The AVVSS improved signicantly in all
groups from 3 days and onward (P < .0001), with no
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS
Volume 1, Number 4
difference between the groups at any point in time (Fig 6).
The mean (standard deviation) AVVSS at the start of the
study was 18.74 (8.63), 17.97 (9.00), 18.38 (9.07), and
19.3 (8.46) and was reduced to 4.43 (6.58), 4.61 (5.8),
4.76 (5.71), and 4.00 (4.87) at 3 years in the CLF, EVLA,
UGFS, and stripping group, respectively.
SF-36 scores. Statistically signicant improvements
compared with baseline were seen in the domains of phys-
ical functioning, role e physical, bodily pain, vitality, social
functioning, role e emotional, and mental health at some
point in time in some of the groups, and in the mental
component summary, and physical component summary
at all time points in all groups. (Table III)
DISCUSSION
Due to recanalization, signicantly more patients in the
UGFS group developed open reuxing GSV segments of
more than 10 cm compared with patients treated with
the other modalities. The majority of recanalizations
appeared within the rst year of follow-up. Our recanaliza-
tion rate is probably somewhat higher than previously
described by authors using sodium tetradecyl sulfate in
a similar volume, but it seems to be as good, or even better,
than previously described after catheter-directed foam scle-
rotherapy with Polidocanol.17-19 Our protocol did not
allow retreatment beyond the rst month, and only ve
patients (ve legs) received such retreatment.11 Further
sessions of UGFS would undoubtedly have improved the
closure rate. The failure to strip the GSV occurred in eight
legs because the vein snapped during the procedure and
could not be retrieved. Accordingly, this failure represents
a technical error, which is well known. No difference in
GSV recanalization or failure to strip the vein (failure
rate) was found between thermoablation and stripping.
Our nding is in line with previous studies comparing
EVLA with stripping, showing no difference in efcacy of
the two treatments.20-22 Our study is the rst to compare
CLF with the other modalities medium term in a random-
ized trial. It shows that the efcacy of GSV ablation with
CLF is not different from EVLA and stripping but consid-
erably better than UGFS. The longer-term clinical impact
of recanalized segments of the GSV is not known, however.
In the present study with 3-year follow-up, GSV recanaliza-
tion or failure to strip was not associated with clinical recur-
rence nor did it seem to inuence VCSS or QOL.
The clinical recurrence rate, as dened by the presence
of varicose veins after treatment (REVAS), was high in all
the groups, with no difference between the groups.4
Such recurrence is well known from other studies where
varicose veins are carefully sought for, and it may well reach
more than 60% of legs after 11 years.5-7 The REVAS clas-
sication was not different between the groups, thus
a previous nding of increased neovascularization in the
groin after stripping compared with EVLA could not be
conrmed in the present study.23 However, such changes
were only sought for in legs with REVAS.
More patients in the UGFS group were retreated
compared with the other groups because more GSVs
Rasmussen et al 355
recanalized in this group. It is standard practice in our
clinics to offer retreatment in patients with a recanalized
GSV following a primary treatment. Thus, the retreatment
with foam was not necessarily performed because of symp-
toms or recurrent varicose veins. All four treatments signif-
icantly improved VCSS and QOL as reected by signicant
improvements in AVVSS and in several domains of SF-36,
with no signicant differences in the outcome between
the groups. The improvements persisted throughout the
3 years and show that CLF, EVLA, UGFS, and stripping
are efcient treatments with longer-term benecial effects
in patients with GSV varicose veins. This is true even
though more patients in the UGFS group developed recan-
alization of the GSV. One explanation may be the fact that
all treatments were combined with miniphlebectomies.
Thus, recanalization or failure to strip the GSV does not
appear to inuence the VCSS and QOL in this study.
A shortcoming of the study is that it was not blinded.
Whereas a study comparing different thermoablation
modalities may be blinded, it is not possible to blind the
treatment for the patient in a study such as ours. Blinding
of the observer may be possible, but it is difcult. It should
be noted however, that QOL data are based on the
patients own completions of questionnaires. Furthermore,
during follow-up visits, the observer would have no access
to information of the primary procedure and little recollec-
tion of it.
In conclusion, our study demonstrates that CLF,
EVLA, UGFS, and stripping are efcient modalities for
the treatment of GSV varicose veins in the medium term.
Apart from a higher rate of recanalization after UGFS, it
appears that there is no difference regarding clinical recur-
rence, VCSS, and QOL.
AUTHOR CONTRIBUTIONS
Conception and design: LR, LB, BE
Analysis and interpretation: LR, ML, JS, AB
Data collection: LR, JS, LB, BV
Writing the article: LR, ML, AB
Critical revision of the article: LR, ML, JS, AB, BE, BV
Final approval of the article: LR, ML, LB, JS, AB, BE, BV
Statistical analysis: LR, ML, AB
Obtained funding: LR
Overall responsibility: LR
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INVITED COMMENTARY
Cynthia K. Shortell, MD, Durham, NC
In 2011, the authors published the initial 1-year results of this
large randomized controlled trial comparing endovenous laser
ablation, radiofrequency ablation, ultrasound-guided foam sclero-
therapy, and surgical stripping in the treatment of symptomatic
reux of the great saphenous vein. This study quickly became
the most important work comparing the four treatment modalities,
as it provided comprehensive and scientically rigorous data on all
important aspects of therapeutic outcomes: anatomic, functional,
quality of life, and cost. At 1 year, thermal ablation and surgical
stripping were superior to foam sclerotherapy with regard to
anatomic outcomes but not to quality-of-life metrics, although
sclerotherapy was associated with reduced cost compared with all
October 2013
Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg
2010;52:1387-96.
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with stripping of the great saphenous vein: clinical outcome and
recurrence after 2 years. Eur J Vasc Endovasc Surg 2010;39:630-5.
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Submitted Mar 27, 2013; accepted Apr 29, 2013.
modalities and with faster recovery than laser and surgery. In the
present study, we see that the initial ndings with regard to
anatomic and quality of life persist at 3 years; that is to say that
anatomic results and freedom from reintervention were superior
in the thermal ablation and surgical group compared with the scle-
rotherapy group, but quality-of-life measures were not different.
While the study may not demonstrate clear superiority of one
modality over others, it brings the differences into sharp focus.
We may now share with our patients the options and potential
advantages of each of the possible treatments available to them
and have condence that they will have reliable data on which to
base their decision.